Provider Demographics
NPI:1952387516
Name:WALLACE P BERKOWITZ MD LTD
Entity type:Organization
Organization Name:WALLACE P BERKOWITZ MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:P
Authorized Official - Last Name:BERKOWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-647-8895
Mailing Address - Street 1:6651 CHIPPEWA
Mailing Address - Street 2:STE 324
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-2538
Mailing Address - Country:US
Mailing Address - Phone:314-647-8895
Mailing Address - Fax:314-647-8898
Practice Address - Street 1:6651 CHIPPEWA
Practice Address - Street 2:STE 324
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-2538
Practice Address - Country:US
Practice Address - Phone:314-647-8895
Practice Address - Fax:314-647-8898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4234207Y00000X
IL207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
100287OtherHEALTHPARTNERS
MOM2229OtherMO MCR SUBMITTER ID
IL08200436OtherBCBS OF IL
2230168OtherAETNA HMO
4376271OtherAETNA PPO
6670OtherBLUE CHOICE
MO6670OtherALLIANCE ALL CHOICE BASIC
MOR4234OtherMO LICENSE NUMBER
1007077OtherUHC
119451OtherHEALTHLINK
MOR4234OtherMO LICENSE NUMBER
119451OtherHEALTHLINK
6670OtherBLUE CHOICE